Overview
Definition:
Groin lymph node dissection (inguinal lymphadenectomy) involves the surgical removal of lymph nodes from the inguinal region
This procedure is often performed for staging and treatment of cancers such as melanoma, squamous cell carcinoma of the lower extremities or perineum, and metastatic disease to the inguinal nodes
Wound management is critical due to the high risk of complications.
Epidemiology:
Inguinal lymphadenectomy is a common oncologic procedure
Complication rates, particularly wound-related issues like infection, seroma formation, and lymphedema, can be significant, affecting up to 50% of patients in some series
Factors like extent of dissection, patient comorbidities, and adjuvant therapies influence complication rates.
Clinical Significance:
Effective wound management post-groin dissection is paramount to prevent morbidity, reduce hospital stay, and facilitate timely adjuvant treatments
Poor wound healing can lead to prolonged recovery, chronic lymphedema, recurrent infections, and psychological distress for the patient
Understanding management principles is crucial for surgical residents preparing for DNB and NEET SS exams.
Indications
Lymphadenectomy Indications:
Therapeutic for biopsy-proven inguinal lymph node metastasis
Staging for high-risk primary tumors (e.g., thin melanomas with sentinel node biopsy positive, vulvar/penile cancers)
Prophylactic in select high-risk cases where metastasis is suspected but not confirmed.
Contraindications:
Active widespread infection
Severe coagulopathy
Patient refusal
Advanced metastatic disease precluding survival benefit
Uncontrolled comorbidities that significantly increase surgical risk.
Preoperative Assessment:
Detailed history including comorbidities (diabetes, peripheral vascular disease, obesity), previous groin surgery or radiation
Physical examination to assess skin integrity, presence of infection, and edema
Nutritional status assessment
Smoking cessation counseling
Optimization of glycemic control and anticoagulation status.
Preoperative Preparation
Patient Counseling:
Informed consent discussing risks, benefits, alternatives, and expected recovery
Education on wound care, drain management, and physiotherapy
Realistic expectations regarding swelling and potential for lymphedema.
Anesthesia Considerations:
General anesthesia or regional anesthesia (spinal/epidural)
Multimodal analgesia to facilitate early mobilization
Consider prophylactic antibiotics covering skin flora (e.g., cefazolin).
Surgical Planning:
Marking of incision lines, considering cosmetic outcomes and potential for flap compromise
Planning for meticulous hemostasis
Consideration of drain placement and type
Techniques to minimize dead space.
Procedure Steps
Incision And Dissection:
Elliptical incision or curvilinear incision
Care to preserve saphenous vein if possible
Dissection of subcutaneous tissue to expose the inguinal ligament superiorly, sartorius muscle laterally, and adductor longus medially
Removal of lymph nodes en bloc.
Hemostasis:
Meticulous control of bleeding using electrocautery, ligatures, and topical hemostatic agents
Small perforators should be coagulated
A dry field is essential for optimal wound closure.
Wound Closure And Drainage:
Reapproximation of subcutaneous tissue to obliterate dead space
Drains (e.g., Jackson-Pratt) are typically placed to prevent seroma formation
Closure in layers with absorbable sutures
Skin closure with staples or absorbable sutures.
Dressing:
Application of sterile dressing, often with a compression element to reduce dead space and prevent hematoma/seroma
Drainage system management
Postoperative Care
Pain Management:
Adequate analgesia (opioids, NSAIDs, acetaminophen)
Consider continuous epidural or peripheral nerve blockade for enhanced pain control and early mobilization.
Drain Management:
Monitor drain output daily
Drains are typically removed when output is less than 30 mL in 24 hours
Early removal can predispose to seroma, late removal to infection.
Mobilization And Physiotherapy:
Encourage early ambulation to prevent deep vein thrombosis and aid lymphatic drainage
Gentle range-of-motion exercises for the hip and knee
Avoid strenuous activity and heavy lifting.
Wound Surveillance:
Regular inspection of the wound for signs of infection, dehiscence, hematoma, or excessive serous drainage
Patient education on signs and symptoms of complications to report promptly.
Complications
Early Complications:
Wound infection: Characterized by erythema, warmth, purulent drainage, fever
Managed with antibiotics and wound care
Seroma: Collection of serous fluid in the wound bed
Management includes aspiration, serial aspirations, or surgical evacuation
Hematoma: Collection of blood, can lead to infection or delayed healing
Management may require surgical evacuation
Wound dehiscence: Separation of wound edges, often due to infection, tension, or poor healing
Requires surgical re-closure.
Late Complications:
Chronic lymphedema: Persistent swelling of the limb due to impaired lymphatic drainage
Managed with compression therapy, physiotherapy, and meticulous skin care
Lymphocele: Encapsulated collection of lymph
May require aspiration or marsupialization
Chronic pain: Persistent neuropathic or musculoskeletal pain in the groin or limb.
Prevention Strategies:
Meticulous surgical technique with excellent hemostasis
Obliteration of dead space through careful tissue approximation
Use of drains
Postoperative compression
Patient education on activity restrictions and monitoring
Prophylactic antibiotics
Optimizing patient comorbidities (e.g., diabetes control)
Careful consideration of adjuvant therapies like radiation which can impair healing.
Key Points
Exam Focus:
High incidence of seroma and lymphedema post-groin dissection
Importance of meticulous hemostasis and dead space obliteration
Management of wound infection and dehiscence
Criteria for drain removal
Recognition and management of chronic lymphedema.
Clinical Pearls:
Consider negative pressure wound therapy (NPWT) for complex or high-risk wounds
Early and aggressive physiotherapy is crucial for lymphedema prevention
Educate patients that swelling and discomfort can persist for months.
Common Mistakes:
Inadequate hemostasis leading to hematoma/seroma
Failure to obliterate dead space
Premature drain removal
Insufficient patient education regarding activity restrictions and warning signs of complications
Aggressive mobilization before wound healing.